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3^New Facility □ Existing Facility San Joaquin County Environmental Health Department Facility Name Supervisor District □ Consultation □ Change of Owner □ Repairs or Remodel □ Other □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect S^Billing Party &Tacility Owner Ortacility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license number Phone Email □ Facility Owner□ Billing Party □ Property Owner □ Contractor □ Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email DATE: PROPERTY / BUSINESS OWNER □ OTHER AUTHORIZED AGENT Title Accepted By Assigned To Linked FA IDS5kL Fee to- □ Cash □ Check « Rev 07/10/2024 Type of Service Requested Comments Contact Types required Supplication for Operating Permit Email - □ Facility Contact If mobile food truck or pumper truck Application Form Site Address _ ' x-x , lm€> $». or APN a^seAI PE 1(pOS i City C\(k^ ft- License Plate Number ’ vM First Name AdHiE> S -Wm & Dattci-i«-a4 Re“'d N“mbe'A P 3 401047 Pavment ./ Received By BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. vCA n . / i rt / ! I APPLICANTS SIGNATURE: t/TVV-viX-J \ '( ■'<-— DATE: ' f I ^'1 BfOPW^TOR / MANAGER If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Or- j AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby ^trtlforijh^e release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONM^Hj^LHEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ..............--........- ... sn,,Cfl Last name Confirmation# | Qj